On assessment a nurse notes that a patient's skin is reddened with a small abrasion. The nurse most correctly will classify this ulcer formation as what stage?
A. I
B. II
C. III
D. IV
B
Stage I is an observable pressure ulcer with warm/cool skin temperature, firm or boggy tissue consistency, sensation of pain or itching. Stage III is loss of skin involving damage or necrosis, presenting as a deep crater with or without undermining of surrounding tissues. Stage IV is a full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or tendon/joint capsule. Undermining and sinus tracts are also present.
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Protein binding
a. Refers to the time required for half the medication to be excreted or inactivated b. Refers to the capacity of proteins in the bloodstream to be binding sites for drugs c. Is how medications move into and through the body d. Refers to the effect of specific medications at the site of action
The physician orders a nasogastric tube (NGT) for the client with pancreatitis. The nurse explains that the purpose of the tube is:
A) relief from nausea and vomiting. B) reduction of pancreatic secretions. C) control of fluid and electrolyte balance. D) removal of irritants.
A resident had 4 incontinent episodes this morning. You are becoming short-tempered and impa-tient. What should you do?
a. Remind the person to use the bedpan. b. Ask the person to use the bathroom every hour. c. Tell the person that other residents need your help. d. Talk to the nurse.
How should the nurse explain the mechanism that causes the skin to become reddened from prolonged exposure to cold?
a) reflex vasodilation occurs following the initial vasoconstricting effects of the cold b) cold causes a numbing sensation, which interferes with circulation at the site c) debris from necrotic tissue collects at the site of vasoconstriction, causing inflammation d) intradermal tissue blisters occur as the result of the damage caused by exposure to cold